NHS Resolution has recently published a new ‘Did You Know?’ advice leaflet which warns NHS organisations and healthcare staff about the risks of anti-infective medication errors. The leaflet follows an analysis of medical negligence claims arising from mistakes in prescribing, dispensing and administering medicines to treat infections, which resulted in patients suffering avoidable injury or death.
Anti-infective medications are used to treat infection. They include antibiotics, antiviral and antifungal drugs. Medical negligence claims for severe injury from infection often relate to negligent delay or failure to diagnose meningitis, sepsis or other infections, or failure to provide urgent or correct treatment for these conditions, resulting in amputations, brain injury or the patient’s death.
Recent investigations by HSIB have highlighted that severe or fatal injury can be caused to adult and child patients from other types of errors after the patient’s need for medication has been recognised and the decision to give the treatment has been made. HSIB’s investigations looked at a wider range of medications, including paracetamol, but identified that 237 million mistakes occur in England every year, during the prescribing, dispensing, administration and monitoring of medication. HSIB reported that 66 million of these mistakes are potentially medically significant.
NHS Resolution’s ‘Did You Know?’ advice leaflet on anti-infective medication errors is based on an analysis of closed claims relating to these types of mistakes, and does not include claims where the patient’s need for anti-infective medication was delayed or not recognised. Their analysis focussed on cases in which compensation was paid after patients were injured as a result of mistakes in prescription, transcription, dispensing, administering and monitoring of medicines which it had been decided they needed to treat a diagnosed infection.
Errors in prescribing and administering anti-infective medication – facts and stats
Excluding claims arising from delay in diagnosis and treatment of infection, in the five year period ending 31st March 2020, the NHS defence organisation, NHS Resolution, received 172 claims relating to anti-infective medications. 68 of these have resulted in compensation settlements and 53 are still ongoing.
The total cost of the closed claims was just over £2.6 million, including compensation paid to patients, and the legal fees for the patients’ claims and the NHS’s defence.
These mistakes in prescription, transcription, dispensing, administering and monitoring of anti-infective medicines led to significant patient harm, including anaphylaxis (severe life-threatening allergic reaction), acute kidney injury, and in some cases the death of the patient.
The claims came from all healthcare specialties. Most related to mistakes in the processes for prescribing, giving and monitoring penicillin, gentamicin and glycopeptides (used for life-threatening infections from drug-resistant Gram-positive pathogens, such as staphylococcus aureus and C.diff).
Common negligent mistakes leading to anti-infective medication error claims included:
- failing to check the patient’s allergy status;
- failing to cross-check the medication ingredients against the patient’s allergy status;
- failing to adjust the dose of medication to the patient’s weight;
- failing to adjust the dose of medication taking account of the patient’s kidney function.
The leaflet includes reminders and advice for NHS organisations and healthcare staff on how to prevent safety incidents from anti-infective medication errors, including:
- checking the British National Formulary (BNF) guidance on monitoring and adjusting antibiotic dosages according to the patient’s weight and kidney function;
- referring to the ‘traffic light system’ which advises on safe use of specific antibiotics and penicillin allergy;
- regularly checking the patient’s weight and adjusting their drug doses accordingly;
- checking the patient’s allergy status at each stage in the medication process;
- reviewing local (e.g. within a hospital trust) guidelines to ensure that they incorporate national (e.g. NICE) guidance and support clinicians to prescribe, administer and monitor the effects of anti-infectives correctly;
- referring to the NICE guidelines on acute kidney injury for information and advice on preventing, detecting and managing acute kidney injury;
- reviewing the NHS organisation’s previous medication error claims and sharing that learning with clinicians.
If you or a family member have been severely injured as a result of medical negligence, you can talk to an experienced solicitor, free and confidentially, to find out more about your entitlement to compensation, by contacting us here.